Provider Demographics
NPI:1871897603
Name:ESCENTUALS MEDICAL SUPPLY
Entity type:Organization
Organization Name:ESCENTUALS MEDICAL SUPPLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/MANAGER OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOLA
Authorized Official - Middle Name:N
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:702-245-1966
Mailing Address - Street 1:5025 S EASTERN AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-2309
Mailing Address - Country:US
Mailing Address - Phone:702-245-1966
Mailing Address - Fax:702-947-2248
Practice Address - Street 1:5025 S EASTERN AVE STE 4
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-2309
Practice Address - Country:US
Practice Address - Phone:702-245-1966
Practice Address - Fax:702-947-2248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies